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Complete Care for Every Woman: An Evidence Based Approach for Clinicians in Women’s Health. Amy Loden, M.D. April 5, 2014 Department of Internal Medicine Washington University in Saint Louis. Case 1. 18y G0 presents for pre-college physical “because my mom is making me” PMH: acne

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Complete care for every woman an evidence based approach for clinicians in women s health

Complete Care for Every Woman: An Evidence Based Approach for Clinicians in Women’s Health

Amy Loden, M.D.

April 5, 2014

Department of Internal Medicine

Washington University in Saint Louis


Case 1
Case 1

  • 18y G0 presents for pre-college physical “because my mom is making me”

  • PMH: acne

  • PSH: tonsillectomy

  • SHx:

    • ½ ppd tobacco, no alcohol or illicit drugs

    • Sexually active with 1 lifetime partner, uses condoms “sometimes”

  • FHx: hypertension (father), obesity (mother)

  • Meds: metronidazole gel


What are your recommendations
What are your recommendations?

  • Pap smear with HPV

  • Pap smear without HPV

  • No pap smear

  • Advise smoking cessation

  • Measure BP and waist

  • Screen for HIV and Chlamydia

  • Screen for glycemic and lipid abnormalities

  • Screen for depression


Case 2
Case 2

  • 23y G0 presents for “irregular periods”

  • ROS: gained 60lbs during college and law school

  • PMH: acne

  • PSH: tonsillectomy

  • SHx: occasional beer, 1/2ppd, no illicits; currently in law school, sexually active with 2 lifetime partners

  • FHx: hypertension (father), obesity (mother)

  • Meds: metronidazole gel

  • Vitals: BP:130/80, BMI 38 with waistline of 35 inches (89cm)

  • Exam: acanthosis nigracans in the axillae, skin tags, hirsutism, no adnexal masses


What are your recommendations1
What are your recommendations?

  • Advise weight loss

  • Start oral contraceptive for presumed polycystic ovarian syndrome

  • Start metformin for presumed insulin resistance

  • Fasting insulin, lipids and hemoglobin a1c

  • AM cortisol, 24 hour urine cortisol

  • TSH, free T4 and free T3

  • AM DHEA, free and total testosterone

  • 17-hydroxyprogesterone level

  • Transvaginal ultrasound


Case 3
Case 3

  • 28y G1P0010 presents “because I want to start a family”

  • PMH: polycystic ovarian syndrome (PCOS), hypertension (HTN), hyperlipidemia (HLD)

  • PSH: tonsillectomy, elective AB (1)

  • SHx: occasional beer, no tobacco or illicits; associate at a local law firm, sexually active with 3 lifetime partners, married and monogamous

  • FHx: hypertension (father), obesity & diabetes (mother)

  • Meds: lisinopril, simvastatin, metformin

  • Vitals: BP:125/75, BMI 33

  • Exam: obese, otherwise normal


What are your recommendations2
What are your recommendations?

  • Advise weight loss

  • Start folic acid

  • Continue lisinopril

  • Stop linsinopril

  • Continue metformin

  • Stop metformin

  • Continue simvastatin

  • Stop simvastatin

  • Screen for HIV

  • Check A1c


Case 4
Case 4

  • 33y G3P2012 presents to your office for “heavy periods”

    • Periods are every 30 days, bleeding lasts 8-12 days, she passes clots the size of a lemon, and she has no inter-mentstrual bleeding

  • PMH: PCOS, HTN, HLD, gestational diabetes (GDM)

  • PSH: tonsillectomy, elective AB (1)

  • SHx: no toxic habits; married & monogomous

  • FHx: HTN, CAD, (father); obesity, DM (mother); HTN (sister)

  • Meds: lisinopril, simvastatin, metformin

  • Exam: BMI 28, normal pelvic and breast exams


What are your recommendations3
What are your recommendations?

  • Pregnancy test,

  • Prolactin level, TSH

  • FSH, LH

  • Ferritin and iron panel

  • CBC

  • Coagulation panel

  • Transvaginal ultrasound

  • Endometrial biopsy

  • Hysteroscopy

  • Endometrial ablation

  • Hysterectomy


Case 5
Case 5

  • 38y G4P2022 presents to “to be sure I don’t get cancer”

  • PMH: PCOS, HTN, HLD, gestational diabetes (GDM)

  • PSH: tonsillectomy, elective AB (1)

  • SHx: no toxic habits; married & monogomous

  • FHx: HTN, CAD, and colon cancer at age 55 (father); obesity, DM and breast cancer at age 60 (mother); HTN (sister)

  • Meds: lisinopril, simvastatin, metformin

  • Vitals: BP 130/80, BMI 28

  • Exam: normal


What are your recommendations4
What are your recommendations?

  • Annual skin exam

  • Mammogram now

  • Mammogram starting age 40-50

  • Colonoscopy now

  • Colonoscopy starting age 45

  • Colonoscopy starting age 50

  • CA-125 level

  • Transvaginal ultrasound

  • Endometrial Biopsy

  • CXR

  • Low radiation chest CT


Case 6
Case 6

  • 48y G4P2022 presents to your office for “hot flashes”

  • ROS: irritability, insomnia and vaginal dryness

  • PMH: PCOS; HTN; HLD; GDM

  • PSH: tonsillectomy, elective AB (1), endometrial ablation

  • SHx: no toxic habits; attorney; married and monogomous

  • FHx: HTN, DM, CAD, colon and breast cancer

  • Meds: lisinopril, simvastatin, metformin

  • Vitals: BP 140/80, BMI 35

  • Exam: vaginal atrophy, anxious affect, appears fatigued


What are your recommendations5
What are your recommendations?

  • Advise increased physical activity

  • Measure FSH

  • Start hormone replacement therapy

  • Start venlafaxine (Effexor)

  • Start paroxetine (Paxil)

  • Start gabapentin (Neurontin)


Case 7
Case 7

  • 58y post-menopausal G4P2022 presents for “shortness of breath” and “fatigue”

  • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, normal mammograms & colonoscopies

  • PSH: tonsillectomy, elective AB (1), endometrial ablation

  • SHx: no toxic habits; attorney; married & monogomous

  • FHx: HTN, DM, CAD, colon and breast cancer

  • Meds: lisinopril, simvastatin, metformin

  • Vitals: BP 150/90, HR 70, BMI 35

  • Exam: obese, otherwise unremarkable


What are your recommendations6
What are your recommendations?

  • Start a rigorous exercise program to lose weight

  • Diet modification

  • Increase blood pressure medication

  • Screen for renal disease

  • Screen for diabetes

  • Screen for thyroid disease

  • Assess lipids

  • EKG

  • Stress test

  • PFTs

  • CXR

  • Start low dose aspirin therapy


Case 8
Case 8

  • 63y post-menopausal G4P2022 presents “to be sure I don’t have osteoporosis”

  • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, GERD, normal mammograms & colonoscopies

  • PSH: tonsillectomy, elective AB (1), endometrial ablation

  • SHx: no toxic habits; attorney; married & monogomous

  • FHx: HTN, DM, CAD, colon and breast cancer

  • Meds: lisinopril, metoprolol, simvastatin, metformin, aspirin, omeprazole

  • Vitals: BP 120/80, HR 60, BMI 30

  • Exam: obese, otherwise normal


What are your recommendations7
What are your recommendations?

  • Reassure

  • Advise calcium carbonate supplement only

  • Advise calcium citrate supplement only

  • Advised calcium-magnesium and vitamin d combined supplement

  • Advise vitamin d supplement only

  • Measure vitamin d level

  • Measure urinary NTX level

  • DEXA testing now

  • DEXA testing at age 65


Case 9
Case 9

  • 68y post-menopausal G4P2022 presents for “urine leaking”

    • Occurs mostly with laughing, coughing, sneezing; +urgency, nocturia and frequency; denies fecal incontinence or hematuria; occurs daily and she has stopped going out due to embarrassment about leaking

  • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, normal mammograms & colonoscopies

  • PSH: tonsillectomy, elective AB (1), endometrial ablation

  • SHx: no toxic habits; attorney; married & monogomous

  • FHx: HTN, DM, CAD, colon and breast cancer

  • Meds: lisinopril, metoprolol, simvastatin, metformin, aspirin, omeprazole

  • Vitals: BP 120/80, HR 60, BMI 30

  • Exam: normal


What are your recommendations8
What are your recommendations:

  • Advise kegel exercises and bladder training

  • Advise weight loss

  • Advice avoidance of irritants (eg, alcohol, caffeine)

  • Start oxybutynin (Ditropan) or tolteradine (Detrol)

  • Urinalysis & urine culture

  • Measure hemoglobin A1c

  • Bladder stress test

  • Measure post-void residual volume

  • Urodynamic testing

  • Cystoscopy

  • Schedule for surgical intervention


Case 10
Case 10

  • 78y G4P2022 presents for “ bloating”

  • ROS: dyspepsia, early satiety, and increased constipation, abdominal girth

  • PMH: former smoker (5 pack years), PCOS, HTN, HLD, DM, GERD normal mammograms & colonoscopies

  • PSH: tonsillectomy, elective AB (1), endometrial ablation

  • SHx: no toxic habits; retired attorney; widowed

  • FHx: HTN, DM, CAD, colon and breast cancer

  • Meds: lisinopril, metoprolol, simvastatin, metformin, aspirin, omeprazole, tolteradine

  • Vitals: BP 120/80, HR 60, BMI 30

  • Exam: vaginal atrophy; no cervical lesions, bleeding or discharge; no appreciable uterine tenderness or adnexal mass on bimanual examination; guaiac negative

  • Labs: CBC, chemistries, TSH all normal


What are your recommendations9
What are your recommendations?

  • Reassure

  • Advise simethicone for flatus

  • Advise ranitidine for worsening acid reflux

  • Advise increased water consumption and otc stool softners, laxatives for constipation

  • Refer for EGD and colonoscopy

  • CA-125 level

  • Transvaginal ultrasound

  • Abdominal CT Abdomen/Pelvis



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